Mal Occlusion / Orthodontic Courses by Indian Dental Academy

CLASSIFICATION
OF
MALOCCLUSION
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Normality is the basis of classification in
orthodontics. It rests on what is known as biologic
continuity, i.e., the most frequently found relationship
of the teeth and of the bones of the face in relation to
each other and to the skull as a whole.
Malocclusion is any perversion of normal
occlusion of the teeth. It is a condition where there is
departure from the normal relation of the teeth to
other teeth in the same arch and to the teeth in the
opposing arch.
In order to acquire a better understanding of the
many deviations from normal occlusion and to assist
in diagnosis and treatment planning, it becomes
necessary to group the varieties of malocclusion into
order. This is difficult as occlusal anomalies are many
and varied. Orthodontics has been described,
admirably, as a Science of Infinite Variations.
Classification is a process of analyzing cases of
malocclusion for the purpose of segregating them into
a small number of groups, which groups are
characterized by certain specific and fundamental
variations from normal occlusion of the teeth.
Classification is an essential communication tool
between dental school professor and student, between
practitioners, and between practitioner and insurance
company or government bureaucracy. It is essential
that everyone "speak the same language."
Classification aids in the diagnosis and treatment
planning of malocclusions by orienting the clinician
to the type and the magnitude of the problems and
possible mechanical solutions to the problems.
Segregation of the countless number of cases of
tooth malposition into a comparatively low number of
groups, each group containing only such cases as are
characterized by a common factor or factors of
fundamental significance.
Ease of reference i.e. giving name to a group of
symptoms making together a single problem
Comparison of cases with other cases having same
problem
Malocclusion can be broadly divided into-
Individual tooth malposition or Intra arch malocclusion
Maxillo-mandibular malocclusions or Inter arch
malocclusion
Individual tooth malposition or Intra arch
malocclusion
A tooth can be abnormally related to its neighboring
teeth, such abnormal variations are called individual
tooth malpositions or intra arch malpositions. Some of
the commonly seen individual tooth malpositions are
Distal inclination or distal tipping
Mesial inclination or mesial tipping
Lingual inclination or lingual tipping
Buccal inclination or buccal tipping
Individual tooth malposition or Intra arch
malocclusion
Mesial displacement
Distal displacement
Lingual displacement
Buccal displacement
Infraversion or infraocclusion
Supraversion or supra occlusion
Disto lingual or mesio buccal rotation
Mesio lingual or disto buccal rotation
Transposition
MESIAL
INCLINATION
DISTAL
INCLINATION
LINGUAL AND LABIAL
INCLINATION
MESIAL
DISPLACEMENT
DISTAL
DISPLACEMENT
INFRAVERSION SUPRAVERSION LINGUAL AND LABIAL
DISPLACEMENT
TORSIVERSION
TRANSPOSITION
Inter arch malocclusions
These malocclusions are characterized by abnormal
relationships between two teeth or groups of teeth of one
arch to the other arch. These inter arch malocclusion can
occur in
Sagital plane
Vertical plane
Transverse plane
Sagital plane malocclusions
Pre-normal occlusion- refers to a condition where the
lower arch is more forwardly placed when the patient
bites in centric occlusion.
Post-normal occlusion- a condition where the lower
arch is more distally placed when the patient bites in
centric occlusion.
Vertical plane malocclusions
Deep bite or increased over bite: this refers to a
condition where there is an excessive vertical overlap
between upper and lower anterior teeth.
Open bite: is a condition where there is no vertical
overlap between upper and lower teeth . Thus a space
exist between the upper and lower teeth when the patient
bites in centric occlusion. Open bite can be in anterior
or posterior region.
Transverse plane malocclusions
Cross bite refers to a condition in which mandibular
teeth overlap their maxillary antagonists. Cross bite can
be anterior or posterior
Buccal Non occlusion refers to a condition in which
maxillary posteriors are completely buccally placed in
relation to mandibular antagonists without occluding
Palatal Non occlusion refers to a condition in which
maxillary posteriors are completely palatally placed in
relation to mandibular antagonists without occluding
Angle believed that since biologic entities as
well as inanimate elements can be arranged into
well-defined classes, the same held also of the
occlusion of the teeth and the shape of the face.
Angle based his classification of malocclusion
on the normal mesiodistal relations of the
mesiobuccal cusps of the upper first molars in
relation to the mandibular first molars.
Basis for Angles classification
Most indicative irregularity of teeth found in antero-posterior
relationship of the teeth and the jaws.
There is a normal mesio distal or antero-posterior position for
the body of the mandible with its superimposed mandibular
dental arch to occupy in the anatomy of the skull.
The maxillary dental arch being built upon a base that is a
fixed section of the skull anatomy, is more or less stable in its
relationship to various landmarks on the head and consequently
the first molar teeth in this arch may be quite safely selected as
a key tooth from which to judge the relationship of mandibular
dental arch and intern to the body of mandible upon which it is
located
Basis for Angles classification
If there is shifting of maxillary molars in their
relationship to the skull anatomy, this variation can be
detected by changes in the axial inclination of teeth in
the maxillary arch. The axial change is especially
manifested by canine teeth.
Curvature and line of occlusion is unique to each
individual.

Angle used the Roman numerals I, II and III to
designate the three main classes of mesiodistal arch
relationship viz., Class I or normal, Class II or distal and
Class III or mesial relationship of the cusps of the
mandibular first molars to the maxillary first molars.
He employed the Arabic numerals 1 and 2 to
denote divisions of the classifications. Unilateral
deviations he termed subdivisions.

Angle classified malocclusion as follows
Class I
Class II
Division 1
Division II
Subdivision
Class III
Subdivision

Class I Malocclusion
The mandibular dental arch and the body of the
mandible are in normal relation to the maxillary arch
indicated by the fact that mesiobuccal cusp of the
maxillary first permanent molar occludes in the buccal
groove of the mandibular permanent first molar and
the mesiolingual cusp of the maxillary first molar
occludes with the occlusal fossa of the mandibular first
permanent molar when the jaws are in centric
occlusion

Class II Malocclusion
mandible are in distal relation to the maxillary arch by
half the width of the maxillary first permanent molar or
mesioodistal width of a premolar indicated by the fact
that mesiobuccal cusp of the maxillary first permanent
molar occludes in the space between the mesiobuccal
cusp of the mandibular permanent first molar and the
buccal cusp of the second premolar.
The mesiolingual cusp of the maxillary first molar
occludes mesial to the mesiolingual cusp of the
mandibular first permanent molar when the jaws are in
centric occlusion.

Division I
A class I I malocclusion in which maxilary incisors
are in labioversion
Subdivision
A class I I division I malocclusion occuring on
only one side
Division I I
A class I I malocclusion in which maxilary incisors
are not in labioversion rather they are retroclined
with laterals overlapping centrals or canines
overlapping laterals
Subdivision
A class I I division I malocclusion occuring on
only one side
Class III Malocclusion
mandible are in mesial relationship to the maxillary
arch indicated by the fact that mesiobuccal cusp of the
maxillary first permanent molar occludes in the
interdental space between the distal aspect of the distal
cusp of the mandibular first permanent molar and the
mesial aspect of the mesial cusp of the second
permanent molar

Class III Malocclusion
Subdivision
A class I I I malocclusion in which malocclusion is
only unilaterally
Pseudo-Class III Malocclusion
I n this condition the mandible is protruded a little during
the final stages of closure in order to avoid a premature
contact of incisors or canines
This is most likely to arise in cases where the relationship
of the incisors is edge-to-edge, and may be caused by a
mildly prenormal relationship of the dental bases
Such pseudo or postural Class I I I cases may tend, if
left untreated, to become established by a further
development of the whole occlusion in Class I I I relation.
Features True Class III Pseudo Class III
1 Profile Concave Straight to concave
2 Etiology Hereditary Habitual/developmental
3 Premature
contacts
Absent Present
4 Path of closure Forward Deviated
5 Gonial angle Increased/decreased Normal
6 Retrusion of
mandible
further
Not possible Possible
7 Treatment Orthopedic or
surgical
Elimination of prematurities,
replacement of lost posterior
teeth
8 Left untreated No further changes Becomes established into true
class III
Differences between true and pseudo class III malocclusion
Drawbacks of Angles Classification
The Angle classification was readily accepted
by the dental profession, since it brought order out of
what previously had been confusion regarding dental
relationships. It was recognized almost immediately,
however, that there were deficiencies in the Angle
system.
Angle considered malocclusion only in antero-posterior
plane
Angle considered maxillary first permanent molar as a
fixed point but it was not found so
The classification cannot be applied if first permanent
molars are missing or extracted
The classification cannot be applied in the deciduous
dentition
The classification does not differentiates between
skeletal and dental malocclusions
The classification does not highlight the etiology of the
malocclusion
Individual tooth malpositions have not been considered
in the classification
Lischer introduced the following terms which are
widely used to describe the varieties of malocclusion. He
substituted the term Class I, Class II, Class III given by
angle with the terms Neurtro-occlusion, Disto-occlusion and
Mesio-occlusion.
Neutro-occlusion: Normal relation of dental
arches. It is synonymous with Angles Class I
malocclusion.
Disto-occlusion: Synonymous with Angles Class
II, used to describe all cases of post-normal
occlusion.
Mesio-occlusion: Synonymous with Angles Class
III and describes all cases of prenormal occlusion.
He gave the suffix version to describe the
wrong position of individual teeth as follows:
Linguo versionLingual placement
Labio versionLabial placement
Mesio versionMesial placement
Disto versionDistal placement
Infra versionIntrusion of teeth
Supra versionExtrusion of teeth
TorsiversionRotation
PerversionImpacted tooth
Dewey proposed a modification of the
Angles classification of malocclusion. He
divided the Angles class I into five types and
Angles Class III into three types. There were no
modifications for Class II. He considered the
same molar relationship as in Angles
classification
Modification of Angles Class I
Type 1. Bunched or crowded maxillary anterior teeth.
The canines may be in labioversion or infraversion. All
other versions of individual teeth may be present
Type 2. Maxillary incisors in labioversion
Type 3. The maxillary incisor teeth are in linguoversion
to the mandibular incisors
Type 4. The molars, occasionally also premolars are in
linuoversion or labiobversion but canines and incisors
are in normal relation
Type 5. The molars are in mesioversion due to shifting
following loss of teeth anterior to molars
Modification of Angles Class III
Type 1. The dental arches are well formed and the teeth
are in normal alignment when viewed individually but
there is edge-to-edge bite in anterior region
Type 2. The mandibular incisors are crowded and in
lingual relation to the maxillary incisors
Type 3. The maxillary arch is underdeveloped. The
maxillary incisor are crowded. The mandibular arch is
well developed and the mandibular teeth are in normal
aligment
Sir Norman Bennett introduced a classification of
abnormalities of occlusion which was based on their etiology.
Briefly the classification is as follows:
Class I - Abnormal position of one or more teeth due to local
causes.
Class II - Abnormal formation of a part or whole of either arch
due to developmental defects of bone.
Class III- Abnormal relationship between upper and lower
arches, and between either arch and facial contour and
correlated abnormal formation of either arch.
Since growth of the face and jaws occurs in the three
planes of space-height, width and depth, abnormalities also
occur in any one or more of the foregoing planes.
Simons craniometric classification relates the denture to
the face and cranium in the three planes of space,
(1) The Frankfort horizontal
(2) The Orbital plane and
(3) The raphe or median sagittal plane.
The Frankfort horizontal plane
The Frankfort horizontal plane or the eye-ear plane
is determined by drawing a straight line through the margin of
the bony orbit directly under the pupil of the eye, to the upper
margin of the auditory meatus (the notch above the tragus of the
ear). This plane is used to determine deviations in the height of
the dental arches and teeth in relation to the face and cranium.
The Frankfort horizontal plane
The Orbital plane
The orbital plane is a perpendicular at right angles
to the eye-ear plane at the margin of the bony orbit directly
under the pupil of the eye. This plane is used to determine
sagittal deviations of the dental arches and the axial inclination
of the teeth to the face and the cranium.
The Orbital plane
The Raphe or Median Sagittal plane
The Raphe or Median Sagittal plane is determined
by points approximately 1.5 cm apart on the median raphe of
the palate. The raphe median plane passes through these two
points at right angles to the Frankfort horizontal plane. This
plane is used to determine the deviations in the general form
and width of the dental arches and the axial inclination of the
teeth in relation to the midline of the palate and the head
The Raphe or Median Sagittal plane

The Law of the Canine
In normal arch relationship, according to Simon,
the orbital plane passes through the distal axial aspect of the
canine. This is known as The law of the canine.
Deviation from the raphe or median sagittal plane .
Arch form and inclination of tooth axis are determined
from this plane.
Contraction: A part or all of the dental arch is contracted
toward the raphe median plane. The abnormality may be
mandibular, alveolar, dental, anterior, posterior, unilateral or
bilateral.
Distraction: A part or all of the dental arch is wider than
usual from the raphe median plane
Deviations from the Frankfort horizontal plane:
The angle between the Frankfort horizontal and the
occlusal plane, the form of the occlusal curve, and the
inclination of the teeth axes are determined from this plane.
Attraction: The distance between the occlusal plane and the
FH Plane is comparatively shorter than normal. This
distance is as a rule normally shorter in the young than in
older persons and in some ethnic groups.
Abstraction: The distance between the occlusal plane and
the FH plane is comparatively longer than normal.
Deviations from the Orbital plane:
Sagittal symmetry and inclination of the axes of the teeth
are determined from this plane.
Protraction: The teeth, one or both dental arches, and or
jaws are too far forward. Normally the orbital plane passes
through the distal incline of the canine.
Retraction: The teeth, one or both dental arches and or
jaws are too far retruded. The orbital plane passes too far
anteriorly to the canines.
Deviations of the dental arches in relation to the orbital plane,
according to Simon, may occur as follows:
Both the jaws in normal relation to each other
Upper jaw normal, lower jaw distal
Upper jaw normal, lower jaw mesial
Lower jaw normal, upper jaw mesial
Lower jaw normal, upper jaw distal
Upper jaw mesial, lower jaw distal
Upper jaw distal, lower jaw mesial
Malocclusion may or may not be associated with facial
dysplasia. Dental malocclusion may be present in an otherwise
orthognathic face. However, normal occlusion may also be
present in a face which is not orthognathic. Facial skeletal
patterns are divided into
Class 1, in which the profile is orthognathic,
Class 2, where the mandible is retrognathic, and
Class 3, in which the mandible is prognathic.
Classification of the facial skeletal pattern takes into
consideration also the relationship of the teeth as follows:
Skeletal Class 1: The bones of the face and the jaws are in
harmony with one another and with the rest of the head. The
maxilla is slightly ahead of the mandible. The profile is
orthognathic.
Division 1. Local malrelations of incisor, canine or
premolar teeth.
Division 2. Maxillary incisor protrusion.
Division 3. Maxillary incisors in linguoversion.
Division 4. Bimaxillary protrusion.
Skeletal Class 2: Subnormal distal mandibular
development in relation to the maxilla.
Division 1. Maxillary dental arch is narrower than
mandibular and there is crowding in the canine
region, crossbite and reduced vertical height.
Protrusion of the maxillary anterior teeth. The
profile is retrognathic.
Division 2. Lingual inclination of the maxillary incisors.
The lateral incisors may be normal or in
labioversion.
Skeletal Class 3: Overgrowth of the mandible and obtuse
mandibular angle. The profile is prognathic at the mandible.
Ackerman and Proffit proposed a classification scheme for
malocclusions in which five characteristics and their
interrelationships are assessed.
This system is a synthesis of two schemes, the Angle
classification and the Venn diagram, both of which were
proposed late in the nineteenth century by Angle and Venn.
Venn proposed this representation in 1880, and it has
become prominent in symbolic logic for computer use.
INTRA ARCH
ALIGNMENT
IDEAL
CROWDING
SPACING
PROFILE
GROUP 1
GROUP 2
GROUP 3 GROUP 4
GROUP 5
Gp6
Gp7
Gp8
Gp9
VERTICAL DEVIATION
Open Bite anterior
Open bite posterior
Deep bite anterior
Collapsed bite posterior
Skeletal
Dental
Anterior
divergent
Posterior
divergent
Convex
Concave
Straight
TRANSVERSE
DEVIATION
Cross bites
Buccal
Palatal
Unilateral
Bilateral
Skeletal
Dental
SAGITTAL
DEVIATION
Class I
Class II Div1
Class II Div 2
Class III
Skeletal
Dental
TRANS-
SAGITTAL
SAGITO-
VERTICAL
VERTICO-
TRANSVERSE
TRANS-
SAGITO-
VERTICAL
Classification by groups
Common to all dentitions is the degree of alignment and
symmetry of the teeth within the dental arches. This is
represented as the universe (Group 1).
Many malocclusions affect the profile. For this reason,
profile is represented as a major set (Group 2) within the
universe.
Lateral (transverse), anteroposterior (sagittal), and vertical
deviations and their interrelationships (Groups 3 to 9) are
represented by three interlocking subsets within the profile set.
Step 1 in the classification procedure is an analysis of the
alignment and symmetry of the teeth in the dental arches
(interproximal contact relationships).
Alignment is the key word of Group 1; among the
possibilities are ideal, crowding (arch-length deficiency),
spacing, and mutilated. Irregularities of individual teeth
are described, if desired, by the method of Lischer, namely,
the use of the suffix -version to describe the direction of
individual tooth malalignments.
Ideal occlusion, plus many (but by no means all) Angle
Class I malocclusions, would fall into Group 1.
In Step 2 one views the patient's profile.
In the profile view, it should be noted whether the face is
anteriorly divergent (mandible prominent) or posteriorly
divergent (mandible recessive) and whether the lips are
convex (prominent), straight, or concave relative to the
nose and chin. The "divergence" is most often related to the
facial skeleton; lip position is strongly influenced by the
teeth. Lip and mouth posture should also be considered in
the evaluation.
In Step 3 the dental arches are viewed with regard to lateral
dimensions (transverse plane), and the buccolingual
relationships of the posterior teeth are noted.
The term type is used to describe the various kinds of cross-
bite. A judgment is also made as to whether the problem is
basically dentoalveolar or skeletal or due to a combination
of the two.
Buccal and palatal cross bites ( unilateral or bilateral) comes
under this category
In Step 4 the patient and dental arches are viewed in the
anteroposterior dimension (sagittal plane).
In this dimension, the Angle classification system is utilized
and is merely supplemented by stating whether a deviation
is skeletal, dentoalveolar, or a combination. This
information can be derived from observing the patient or
more accurately from a cephalometric head film.
In Step 5 the patient and the dentition are viewed with regard to
the vertical dimension.
Bite depth is used to describe the vertical relationships. The
possibilities are anterior open-bite, anterior deep-bite,
posterior open-bite, or posterior collapsed bite. To
determine whether this is on a skeletal, dentoalveolar, or
combined basis, a cephalometric analysis may be
particularly helpful.
This approach defines nine groups of malocclusions. The
complexity of the orthodontic problem increases with the group
number. Thus, a Group 9 malocclusion is the most complex in
that there is an alignment problem, a problem in profile, and
problems in the lateral, vertical, and anteroposterior dimensions
as well.
Advantages of this classification
This method of classification based on five descriptive characteristics
and defining nine groups of malocclusions overcomes the major
weaknesses of the Angle system
Specifically, arch-length problems, with or without an influence on the
profile, are recognized; the influence of the dentition on the profile is
taken into account
All three planes of space, not just the sagittal plane, are taken into
consideration
The differentiation between dental and skeletal problems is made at the
appropriate level
Diagnosis is inherent in the classification
According to Moyers, Classification of
malocclusion can be based on the origin of the
problem. There are four classes depending on origin
Skeletal or Osseous
Dental
Muscular
Combination of above
The goal of modern orthodontics can be summed up as the
creation of the best possible occlusal relationships within the
framework of acceptable facial aesthetics and stability of the
occlusal result. The classification systems aid in diagnosis and
treatment planning of malocclusions. There is a basic need for a
system of classification of malocclusion that would be adequate
for clinical, semantic and public health purpose and could be
universally employed by those practicing the specialty throughout
the world
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CLASSIFICATION

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